Concept: Incentive program

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Background Financial incentives promote many health behaviors, but effective ways to deliver health incentives remain uncertain. Methods We randomly assigned CVS Caremark employees and their relatives and friends to one of four incentive programs or to usual care for smoking cessation. Two of the incentive programs targeted individuals, and two targeted groups of six participants. One of the individual-oriented programs and one of the group-oriented programs entailed rewards of approximately $800 for smoking cessation; the others entailed refundable deposits of $150 plus $650 in reward payments for successful participants. Usual care included informational resources and free smoking-cessation aids. Results Overall, 2538 participants were enrolled. Of those assigned to reward-based programs, 90.0% accepted the assignment, as compared with 13.7% of those assigned to deposit-based programs (P<0.001). In intention-to-treat analyses, rates of sustained abstinence from smoking through 6 months were higher with each of the four incentive programs (range, 9.4 to 16.0%) than with usual care (6.0%) (P<0.05 for all comparisons); the superiority of reward-based programs was sustained through 12 months. Group-oriented and individual-oriented programs were associated with similar 6-month abstinence rates (13.7% and 12.1%, respectively; P=0.29). Reward-based programs were associated with higher abstinence rates than deposit-based programs (15.7% vs. 10.2%, P<0.001). However, in instrumental-variable analyses that accounted for differential acceptance, the rate of abstinence at 6 months was 13.2 percentage points (95% confidence interval, 3.1 to 22.8) higher in the deposit-based programs than in the reward-based programs among the estimated 13.7% of the participants who would accept participation in either type of program. Conclusions Reward-based programs were much more commonly accepted than deposit-based programs, leading to higher rates of sustained abstinence from smoking. Group-oriented incentive programs were no more effective than individual-oriented programs. (Funded by the National Institutes of Health and CVS Caremark; ClinicalTrials.gov number, NCT01526265 .).

Timely follow-up after hospital discharge may decrease readmission to hospital. Financial incentives to improve follow-up have been introduced in the United States and Canada, but it is unknown whether they are effective. Our objective was to evaluate the impact of an incentive program on timely physician follow-up after hospital discharge.

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Employers often make payment contingent on performance in order to motivate workers. We used fMRI with a novel incentivized skill task to examine the neural processes underlying behavioral responses to performance-based pay. We found that individuals' performance increased with increasing incentives; however, very high incentive levels led to the paradoxical consequence of worse performance. Between initial incentive presentation and task execution, striatal activity rapidly switched between activation and deactivation in response to increasing incentives. Critically, decrements in performance and striatal deactivations were directly predicted by an independent measure of behavioral loss aversion. These results suggest that incentives associated with successful task performance are initially encoded as a potential gain; however, when actually performing a task, individuals encode the potential loss that would arise from failure.

There is a nuanced interplay between the provision of monetary incentives and behavioral performance. Individuals' performance typically increases with increasing incentives only up to a point, after which larger incentives may result in decreases in performance, a phenomenon known as “choking.” We investigated the influence of incentive framing on choking effects in humans: in one condition, participants performed a skilled motor task to obtain potential monetary gains; in another, participants performed the same task to avoid losing a monetary amount. In both the gain and loss frame, the degree of participants' behavioral loss aversion was correlated with their susceptibility to choking effects. However, the effects were markedly different in the gain and loss frames: individuals with higher loss aversion were susceptible to choking for large prospective gains and not susceptible to choking for large prospective losses, whereas individuals with low loss aversion choked for large prospective losses but not for large prospective gains. Activity in the ventral striatum was predictive of performance decrements in both the gain and loss frames. Moreover, a mediation analysis revealed that behavioral loss aversion hindered performance via the influence of ventral striatal activity on motor performance. Our findings indicate that the framing of an incentive has a profound effect on an individual’s susceptibility to choking effects, which is contingent on their loss aversion. Furthermore, we demonstrate that the ventral striatum serves as an interface between incentive-driven motivation and instrumental action, regardless of whether incentives are framed in terms of potential losses or gains.

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Companies often provide incentives for employees to maintain healthy lifestyles. These incentives can take the form of either discounted premiums for healthy-weight employees (“carrot” policies) or increased premiums for overweight employees (“stick” policies). In the three studies reported here, we demonstrated that even when stick and carrot policies are formally equivalent, they do not necessarily convey the same information to employees. Stick but not carrot policies were viewed as reflecting negative company attitudes toward overweight employees (Study 1a) and were evaluated especially negatively by overweight participants (Study 1b). This was true even when overweight employees paid less money under the stick than under the carrot policy. When acting as policymakers (Study 2), participants with high levels of implicit overweight bias were especially likely to choose stick policies-often on the grounds that such policies were cost-effective-even when doing so was more costly to the company. Policymakers should realize that the framing of incentive programs can convey tacit, and sometimes stigmatizing, messages.

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Behavioral economics provides insights about the development of effective incentives for physicians to deliver high-value care. It suggests that the structure and delivery of incentives can shape behavior, as can thoughtful design of the decision-making environment. This article discusses several principles of behavioral economics, including inertia, loss aversion, choice overload, and relative social ranking. Whereas these principles have been applied to motivate personal health decisions, retirement planning, and savings behavior, they have been largely ignored in the design of physician incentive programs. Applying these principles to physician incentives can improve their effectiveness through better alignment with performance goals. Anecdotal examples of successful incentive programs that apply behavioral economics principles are provided, even as the authors recognize that its application to the design of physician incentives is largely untested, and many outstanding questions exist. Application and rigorous evaluation of infrastructure changes and incentives are needed to design payment systems that incentivize high-quality, cost-conscious care.

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Many programs being implemented by US employers, insurers, and health care providers use incentives to encourage patients to take better care of themselves. We critically review a range of these efforts and show that many programs, although well-meaning, are unlikely to have much impact because they require information, expertise, and self-control that few patients possess. As a result, benefits are likely to accrue disproportionately to patients who already are taking adequate care of their health. We show how these programs could be made more effective through the use of insights from behavioral economics. For example, incentive programs that offer patients small and frequent payments for behavior that would benefit the patients, such as medication adherence, can be more effective than programs with incentives that are far less visible because they are folded into a paycheck or used to reduce a monthly premium. Deploying more-nuanced insights from behavioral economics can lead to policies with the potential to increase patient engagement and deliver dividends for patients and favorable cost-effectiveness ratios for insurers, employers, and other relevant commercial entities.

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Studies on crowding out document that incentives sometimes backfire-decreasing motivation in prosocial tasks. In the present research, we demonstrated an additional channel through which incentives can be harmful. Incentivized advocates for a cause are perceived as less sincere than nonincentivized advocates and are ultimately less effective in persuading other people to donate. Further, the negative effects of incentives hold only when the incentives imply a selfish motive; advocates who are offered a matching incentive (i.e., who are told that the donations they successfully solicit will be matched), which is not incompatible with altruism, perform just as well as those who are not incentivized. Thus, incentives may affect prosocial outcomes in ways not previously investigated: by crowding out individuals' sincerity of expression and thus their ability to gain support for a cause.

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Health worker shortage in rural areas is one of the biggest problems of the health sector in Ghana and many developing countries. This may be due to fewer incentives and support systems available to attract and retain health workers at the rural level. This study explored the willingness of community health officers (CHOs) to accept and hold rural and community job postings in Ghana.